Broward Sheriff`s Office Academic Internship Application

Broward Sheriff’s Office
Academic Internship Application
INSTRUCTIONS
Broward Sheriff’s Office
Department of Community Programs
2926 North State Road 7
Lauderdale Lakes, FL, 33313
Shevrin_Jones@sheriff.org
(954) 375-6272
Online: www.sheriff.org
PLEASE USE BLACK INK AND PRINT CLEARLY OR TYPE.
DO NOT leave any areas blank. Resumes may NOT SUBSTITUTE for any
information requested on this application. INCOMPLETE APPLICATIONS
WILL NOT BE PROCESSED.
The Broward Sheriff’s Office is an equal opportunity employer and does not discriminate on the basis of age, citizenship, color, disability, marital status,
national origin, race, religion, sex, or sexual orientation. These factors are NOT used as selection criteria, except in rare instances where such factors are
bona fide occupational qualifications. This information may be used, however, for identification purposes in conducting a background investigation.
In accordance with the “Americans with Disabilities Act of 1990”, the Broward Sheriff’s Office will reasonably accommodate qualified individuals with a
disability. The reasonable accommodation requirement applies to the application process, any internship test, interview, and actual internship. If you are
disabled and require accommodation, you may request it and the Broward Sheriff’s Office will make every reasonable endeavor to provide it to you.
However, some types of accommodations may require some preparation before they can be provided. Therefore, we suggest that you make such
requests in writing as early as possible by contacting the Bureau of Human Resources.
PERSONAL INFORMATION:
Social Security Number
Last Name
First Name
Middle Name
Residential Address (No PO Box)
Apt.
City
State
Zip Code
E-Mail Address
Home Phone
Work Phone
Extension
Cell Phone/Other
U.S. Citizen:  By Birth
 Naturalized
If not a citizen, are you legally authorized to work in the U.S.?
Have you ever used any other name?
Last Name
 YES
 NO
 YES
 NO
If YES, please list those names below:
First Name
Middle Name
From (mm/yy)
To (mm/yy)
First Name
Middle Name
From (mm/yy)
To (mm/yy)
Reason
Last Name
Reason
By signing this document, I certify that all of the information on this entire application is true and complete to
the best of my knowledge. I understand that all information is subject to investigation and that omission,
falsification, or misrepresentation is sufficient cause for rejection of this application, removal of my name
from consideration, or dismissal from service.
Signature
Date
For Office Use Only:
CS: ____________Code: __________
BSO COP#10 (New 07/16)
1
EDUCATION/TRAINING
Are you a high school graduate?
 YES
High School Name
 NO
 GED
City
State
Are you currently enrolled in a college program that requires you to complete an internship for school credit?
 YES
 NO
Name of School
Current Classification
 Freshman
 Sophomore
 Junior
 Senior
 Graduate Student
Hours Needed
Deadline to Complete Hours
Faculty Advisor’s Name
Faculty Advisor’s Phone Number
Faculty Advisor’s E-mail Address
Additional Colleges/Universities Attended
 Check here if not applicable
College/University
City
To (mm/yy)
State
Total Credit Hours__________
From (mm/yy)


Semester
Quarter
Field of Study
Type of Degree Earned
Date of Degree (mm/yy)
College/University
City
To (mm/yy)
State
Total Credit Hours__________
From (mm/yy)


Semester
Quarter
Field of Study
Type of Degree Earned
Date of Degree (mm/yy)
EMERGENCY CONTACT INFORMATION
Name
Street Address
City, State & Zip Code
Home Phone:
Cell Phone:
Work Number:
AVAILABILITY
Please specify the days and hours you are available to complete your internship. (i.e. 1pm – 5pm or select ANYTIME)
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
 ANYTIME
 ANYTIME
 ANYTIME
 ANYTIME
 ANYTIME
 ANYTIME
 ANYTIME
BSO COP#10 (New 07/16)
2
EMPLOYMENT HISTORY
LIST ALL FULL-TIME, PART-TIME, TEMPORARY and SELF-EMPLOYMENT you have had during the last 7 years, ensuring that
ALL time is accounted for. Start with your CURRENT employment.
Employer
Position
Total Hours Per Week _________
To (mm/yy)
From (mm/yy)

Full Time

Part Time

Full Time

Part Time

Full Time

Part Time

Full Time

Part Time

Full Time

Part Time

Full Time

Part Time
Salary $
Detailed Job Duties
Employer
Position
Total Hours Per Week _________
To (mm/yy)
From (mm/yy)
Salary $
Detailed Job Duties
Employer
Position
Total Hours Per Week _________
To (mm/yy)
From (mm/yy)
Salary $
Detailed Job Duties
Employer
Position
Total Hours Per Week _________
To (mm/yy)
From (mm/yy)
Salary $
Detailed Job Duties
Employer
Position
Total Hours Per Week _________
To (mm/yy)
From (mm/yy)
Salary $
Detailed Job Duties
Employer
Position
Total Hours Per Week _________
To (mm/yy)
From (mm/yy)
Salary $
Detailed Job Duties
BSO COP#10 (New 07/16)
3
ADDITIONAL EMPLOYMENT INFORMATION
1. Have you ever been dismissed from any employment; been asked to resign from any employment; resigned from any employment
following allegations of misconduct or unsatisfactory performance; or left a job by mutual agreement?
 YES
 NO
If YES, please provide details below. Please be specific and attach additional pages if necessary.
Date (mm/dd/yy)
Name of Agency/Employer
Position
Reason/Outcome
2. Have you ever received an unsatisfactory performance evaluation(s) or any disciplinary action(s), including verbal or written reprimands,
from an employer?
 YES
 NO
If YES, please provide details below. Please be specific and attach additional pages if necessary.
Date (mm/dd/yy)
Name of Agency/Employer
Position
Circumstances
3. Have you ever performed any service for any law enforcement agency or been employed by any law enforcement, corrections or public
service agency not listed in this application?
 YES
 NO
If YES, please provide details below. Please be specific and attach additional pages if necessary.
From (mm/dd/yy)
To (mm/dd/yy)
Name of Agency/Employer
Position
Reason for Leaving
DRIVING HISTORY
List ALL driver’s licenses issued to you, starting with your current driver’s license.
State
Type
Is your driver’s license CURRENTLY valid?
Issue Date (mm/yy)
 YES
Expiration/Surrender Date (mm/yy)
 NO
Has your driver’s license EVER been revoked/suspended or have you ever been refused a driver’s license?
 YES
 NO
If you answered Yes, please provide details:
MILITARY
Have you ever served in the Armed Forces of the United States (including Reserves and National Guard)?
DD-214 Member 4 Form must be provided for each enlistment period.
Branch of Military
 YES
 NO
List All Disciplinary Offenses
 NONE
To (mm/yy)
From (mm/yy)
List All Disciplinary Action(s), including non-judicial punishment(s).
 NONE
Character of Service (Box 24
on DD-214 Member 4 Form)
BSO COP#10 (New 07/16)
4
CONTROLLED SUBSTANCES
Current employees of the Broward Sheriff’s Office are not required to complete this page.
Do you NOW, or have you EVER tried, purchased or sold any illegal drugs or controlled substances? (“Tried” includes smoking; inhaling;
swallowing; placing/rubbing on gums, lips, or tongue; injecting; or ingesting by any other means.)  YES  NO
Please be advised that if you are extended a conditional offer of internship, you may be required to provide information regarding
frequency of controlled substance use.
Do you NOW, or have you EVER purchased or sold any illegal drugs or controlled substances?
 YES
 NO
Have you ever used marijuana?  YES  NO
If yes, when was the last time you used marijuana? (mm/dd/yy) _________________________________
Have you ever used cocaine?  YES  NO
If yes, when was the last time you used cocaine? (mm/dd/yy) ___________________________________
Have you ever used anabolic steroids?  YES  NO
If yes, when was the last time you used anabolic steroids? (mm/dd/yy) ____________________________
Have you ever used any other controlled substance not listed above, such as ecstasy, mushrooms, acid, oxycontin, or heroin?
NAME OF DRUG:
 YES
 NO
LAST TIME USED:
CRIMINAL HISTORY
CHARGES When applying for a position with a law
enforcement agency, ALL arrests and charges must be
disclosed, regardless of the disposition. These include, but
are not limited to, all charges that have been dismissed/no
action; found not guilty; sealed, expunged and/or purged;
“Withheld Adjudications”; and Juvenile charges.
Have you EVER been arrested or detained by ANY law enforcement
agency for ANY reason? This includes arrests or detentions [held for
questioning, Notice to Appear or Promise to Appear] as a juvenile or for
violations which were not prosecuted or where some type of pre-trial
intervention was offered, and includes all arrests regardless of your plea.
CONVICTIONS The circumstances surrounding the
conviction are considered, such as: the nature, number,
severity, date of the offense, subsequent history, efforts at
rehabilitation, and relation of the offense to the requirements
of the position for which you are applying. Most
misdemeanor convictions are not an automatic
disqualification for employment.
Have you EVER been convicted of, or have you EVER been found to
have committed any civil or criminal law violation other than minor
traffic violations?
 YES
 YES
 NO
 NO
Have you EVER had a criminal charge or record sealed, expunged
or purged?
 YES
 NO
If YES, please LIST ALL CRIMINAL AND CIVIL LAW VIOLATIONS. Copies of all court dispositions must be submitted with
application. Be sure to include charges from all states, regardless of the outcome or timeframe. Attach additional pages if
necessary.
Charge, Violation, or Circumstances
Date (mm/dd/yy)
Location (City & State)
Detention, Disposition, or Penalty
Date (mm/dd/yy)
Please explain disposition
Charge, Violation, or Circumstances
Date (mm/dd/yy)
Location (City & State)
Detention, Disposition, or Penalty
Date (mm/dd/yy)
Please explain disposition
BSO COP#10 (New 07/16)
5
DISTINGUISHING MARKS, TATTOOS OR PIERCINGS
The Broward Sheriff's Office has a Dress Code policy to include the following:
Employees and Interns are prohibited from piercings (except normal piercing of the earlobe).
The use of gold, platinum, or other veneers or caps for purposes of dental ornamentation is prohibited.
Employees and Interns are prohibited from intentionally altering, modifying, or mutilating any part of their bodies in
order to achieve a visible physical effect that disfigures, deforms or otherwise detracts from a professional image.
Tattoos/body art/brands visible anywhere on the body that are extremist, indecent, sexist, or racist are prohibited.
Tattoos/body art/brands anywhere on the head, face, and neck above the shirt collar are prohibited.
Excessive tattoos/body art/brands are prohibited. Excessive is defined as exceeding 1/4 of the exposed body part.
Prior to being employed, candidates accepting an offer of an internship will be required to disclose in writing
the existence of any visible tattoos/body art/brands and must complete removal of inappropriate tattoos/body art/brands.
Do you have any distinguishing mark, tattoo and/or piercing?
 YES
 NO
If yes, on the space provided below, please identify any distinguishing mark, tattoo and/or
piercing:
TYPE (CHECK ONE)
Distinguishing
 Mark  Tattoo  Piercing
Distinguishing
 Mark  Tattoo  Piercing
Distinguishing
 Mark  Tattoo  Piercing
Distinguishing
 Mark  Tattoo  Piercing
DESCRIPTION
LOCATION ON BODY
Please use page 8 of the application to list any additional distinguishing mark/tattoo/piercing that does not
fit in the space provided above.
Please check one of the statements below:

I will comply with the Dress Code policy.

I am unable and/or unwilling to comply with the Dress Code policy.
BSO COP#10 (New 07/16)
6
RESIDENTIAL BACKGROUND
Please list all residential addresses you have lived at during the past 7 years. Please do not use PO Box Addresses. Begin
with your current residence and include any addresses you may have resided at during school or the military. Attach additional pages
if necessary.
From (mm/yy)
To (mm/yy)
BSO COP#10 (New 07/16)
Street Address
City
State
Zip Code
7
FDLE BACKGROUND INVESTIGATION WAIVER
8
Broward Sheriff’s Office
Department of Community Programs
2926 North State Road 7
Lauderdale Lakes, FL, 33313
Shevrin_Jones@sheriff.org
(954) 375-6272
Online: www.sheriff.org
ATTEST, CONSENT, AUTHORIZE, AND RELEASE
I, _______________________________________________________________________________________________,(PRINT YOUR FULL NAME)
thoroughly understand that I am being considered for an internship in the position for which I have applied, and consent to submitting to a background
investigation and other selection processes which may include, but not be limited to: fingerprint processing, polygraph, post-conditional employment offer
medical and/or urinalysis, psychological evaluation, job interview, and other means deemed necessary and proper by the Broward Sheriff’s Office to
complete its investigation as to my fitness and suitability for the classification for which I have applied. I thoroughly understand that I must successfully
complete the above-mentioned process. I am attesting that I understand and meet all of the minimum requirements as stated on the Internship
announcement.
I am seeking an internship on the basis that I know that the Broward Sheriff’s Office, or other individuals or agencies, will develop no unfavorable
information, with the exception of what I have indicated in this application, which has been thoroughly explained by me in detail during the process. By
signing this document, I certify that all of the information contained in this entire application and all documents submitted are true and complete to the
best of my knowledge. I understand that all information is subject to investigation and that omission, falsification, misrepresentation, or other unfavorable
information developed is sufficient cause for removal of my name for consideration for internship or dismissal from service. I further understand that
unfavorable information disclosed during the selection process can and may be forwarded to past/current employers and other law enforcement
agencies.
I understand that the application and all documents submitted are the property of the Broward Sheriff’s Office and non-exempt information contained in
said forms and documents is public record.
I understand that the Broward Sheriff’s Office will not reimburse any expenses I might incur in seeking this position. I recognize that the time required to
process and select employees for this position may be lengthy and time consuming. No promises or commitments are expected by me as to a time when
a decision and/or actual decision might take place.
I understand that unless defined by applicable law, any internship relationship with the Broward Sheriff’s Office is "at will", that I may be discharged at
any time with or without cause, and that this "at will" relationship may not be changed unless authorized, in writing, by the Sheriff.
I understand that the Broward Sheriff’s Office is a Drug-Free Workplace and that employees and/or interns are subject to random drug testing.
I authorize and direct any persons or organizations to release and furnish records and information as may be relevant to determine my fitness
and suitability for an internship in the position for which I have applied.
I further agree to execute any authorizations as may be required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) for
healthcare providers to release the necessary medical information to process my application for internship.
I agree to conform to rules, regulations, and orders of the Broward Sheriff’s Office and acknowledge that these rules, regulations, and orders may be
changed, interpreted, withdrawn, or added to by the Broward Sheriff’s Office at its discretion at any time and without prior notice to me.
This authorization is executed with full knowledge and understanding that information and/or copies of records disclosed shall become the property of the
Broward Sheriff's Office, shall be used for official internship evaluation, and are used as selection criterion only where related to performance of the
internship for which I have applied; that the Broward Sheriff's Office will take appropriate measures to protect aforementioned information and/or copies
of records against unauthorized disclosure; and that certain non-exempt portions of the information and/or copies of records disclosed may be made
available for inspection by third parties pursuant to public records and other laws.
I understand and consent to all of the above statements and conditions.
Date:
Applicant’s Signature:
Applicant’s Address:
AFFIDAVIT
STATE OF____________________________________________________________ COUNTY OF _______________________________________________
Before me personally appeared _________________________________________________________________________ who says that he/she executed the above
instrument of his or her own free will and accord, with full knowledge of the purpose therefore.
Sworn and subscribed in my presence this _____________________ day of _____________________, 20_____________________.
My Commission expires on _____________________, 20_________. Personally Known __________________________________________ -
or
-
Produced Identification _______________________________________________________ Notary Public: ___________________________________________
Type of identification produced: ________________________________________________________________________
BSO COP#10 (New 07/16)
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REQUIRED DOCUMENTS
Below is a list of all required documents that must be submitted with this application. Each document should be
photocopied on a separate piece of paper and must be clear and legible.
PLEASE CHECK ONE
Pages 8 & 9 of the application must be notarized.
Copy
Attached
N/A


Birth Certificate or valid U.S. Passport or Certificate of Naturalization


Social Security Card (with current legal name and signature)


Driver’s License or State ID (with current legal name/address)


Resident Alien Card: front & back (with current legal name)


Unofficial college transcript(s)


Court Disposition(s) for ALL arrests/charges and copies of police reports


DD-214 Member 4 Form (for each enlistment period)


Current Resume


Internship Requirement Verification Form
If selected for an internship you will need to provide ORIGINAL documents for comparison.
BSO COP#10 (New 07/16)
10
INTERNSHIP REQUIREMENT VERIFICATION FORM
This form MUST be completed by your supervising professor and returned with the completed application and all
required documents (listed on page 10). Applications submitted without this completed form will not be processed.
STUDENT’S FULL NAME:
COLLEGE/UNIVERSITY:
INTERNSHIP SEMESTER:
THIS SECTION MUST BE COMPLETED BY COLLEGE/UNIVERSITY REPRESENTATIVE.
Please attach a copy of the business card for the supervising professor.
UNIVERSITY/COLLEGE REQUIREMENTS:
NAME OF INTERNSHIP COURSE/PROGRAM:
NAME OF SUPERVISING PROFESSOR:
MAILING ADDRESS:
E-MAIL ADDRESS:
PHONE NUMBER:
NUMBER OF HOURS TO BE COMPLETED DURING INTERNSHIP:
TOTAL CREDITS STUDENT IS ATTEMPTING TO EARN:
By signing below, I affirm the above listed student is indeed registered and approved for an internship course and/or
program with the college or university, and that I will be the contact at the institution for any matters regarding this
student’s academic internship.
Printed Name
DATE
Signature
BSO COP#10 (New 07/16)
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